Yael Velleman is a WaterAid senior policy analyst on health and hygiene

As world leaders meet at the UN General Assembly to discuss the rise of drug-resistant micro-organisms globally, they would do well to consider the experience of the midwives at Kiomboi hospital, in the Iramba district of Tanzania.

Before a WaterAid intervention earlier this year, Kiomboi’s taps were dry for 23 hours per day, leaving medical professionals faced with a difficult choice: risk the transmission of infection during childbirth because the delivery room and instruments could not be properly cleaned, or prescribe precious antibiotics as a preventive measure, possibly contributing to the emerging problem of drug-resistant infections.

It is difficult to describe what it is like for medical professionals like these, delivering babies and caring for patients in a hospital without adequate access to clean water or proper sanitation. The water supply to the wards runs for just 1 hour per day, medical equipment is washed in the same sink that waste from the maternity ward is disposed into, and expectant mothers wash their babies’ clothes in the dirty water of a nearby river. The only toilet is fetid and dank and the shower is next to an open sewer. Dirty hands and dirty water mean that pathogens spread quickly and babies and their mothers risk infections like sepsis.

In March, when Kiomboi was without water for 3 consecutive weeks, staff told WaterAid they had to turn first to unpredictable collection of rainwater, and then had to send a car to collect water from a river. Without readily available clean water, midwives were not able to do their jobs safely. At least 12 babies developed sepsis during this period, and two of them died. Midwives were then faced with the torturous question of whether those babies’ deaths were their fault: were those infections transmitted in the delivery process?

The experience of Kiomboi is not an isolated one, and although the hospital now has access to clean water, 42% of health-care facilities across Africa do not. It is estimated that one in five deaths among newborns in sub-Saharan Africa and South Asia are caused by sepsis, meningitis, and tetanus. Of these, sepsis is the most dangerous, leading to 18-20% of neonatal deaths.

Many of these infections could have been prevented and babies’ and mothers’ lives saved, had there been clean water, proper sanitation, rigorous hand and environmental hygiene, and infection prevention and control practices – critical to delivering quality health care. Using antibiotics to do the job of clean water, good sanitation, and good hygiene runs counter to good public health practice, and contributes to the global rise in drug-resistant infections.

Antimicrobial resistance crosses all boundaries – be they geographic or socioeconomic - and is a serious threat to public health globally. According to the UK Government's Review on Antimicrobial Resistance published earlier this year, by 2050 up to 10 million people may die every year from drug-resistant infections. This is not just a health problem, but an economic one too. It is thought that growing resistance to antibiotics could not only cost us enormously in loss of lives but could also cost the global economy up to £70 trillion by 2050.

Sustainable water and sanitation infrastructure and services and good hygiene practices that prevent infection in the first place should be part of the fight against antimicrobial resistance. This, along with prudent use of antibiotics and further development of drugs and vaccines, is essential. As an organisation, WaterAid has joined a public pledge to champion the delivery of quality health care as critical to tackling antimicrobial resistance. Along with raising public awareness, we have promised to push national governments, donors, and international organisations on the need for prevention strategies for addressing this emerging crisis.

We do so while continuing to work on the ground to ensure that midwives like those at Kiomboi now have access to clean water, the infrastructure to ensure that they are able to protect mothers and their babies from infection and care for them safely, and the awareness and training to prioritise prevention of infection and reduce reliance on antibiotics. Water, sanitation, and good hygiene are the first line of defence in combating infection and the rise of drug-resistant micro-organisms.

Comments

Domestically, in countries where these problems exist, I think that it is no longer a problem of lack of awareness of the need for such basic public health measures in many of these contexts. It is often a mixture of budgets stretched too thinly, grinding poverty that is unable to support public services, and a lack of political voice and political will to change what can be changed with existing means.
While international advocacy and increased awareness of these issues can be useful, I worry that all the external hand-wringing and banging of our fists on the table for human rights for such things in these contexts is simply not enough.
I am optimistic, however, that economic development and increased accountability that often goes along with that may be the most effective path, in the long term. In the short term, more effective development assistance in health and water, sanitation, and hygiene (WASH) sectors can help in the short-medium term.
Ed Bourque
http://www.edbourqueconsulting.com/

WASH is critical to prevent illness (which would reduce antibiotic use and therefore resistance) and of course WASH in health facilities is essential to deliver safe health care. Where international advocacy could help is if it was directed towards curtailing tax avoidance, financial secrecy, unfair trading rules, etc which would facilitate increased domestic resource mobilisation which could be used for core human rights.

Antimicrobial resistance is an issue that can be seen around the world and is on the rise. In the United States, we take the clean water and sanitation we have for granted. I can’t imagine how difficult it is to provide quality health care in low-income countries due to the lack of clean water and sanitation. Low-income countries are placed in a predicament of providing patients with prophylactic antibiotics or run the risk of transmitting infections through dirty equipment. Therefore, it is important to assist these countries in obtaining clean water so that the use of antibiotics may be reduced. This issue affects the health of everyone globally because these drug-resistant infections can be easily spread. More efforts should be placed on assisting these low-income countries through awareness and funding because we all run the risk of antimicrobial resistance without a solution.

It's incredible how easy it is to take for granted the unlimited free access to sanitary water we have here in the United States of America, and in first-world countries in general. I cannot imagine having to decide between risking causing infection and contamination of my patients, or having to use expensive and limited antibiotics and possibly exacerbating the problem of antibiotic-resistant bacteria. It is extremely frustrating since this dilemma is a matter of funding, awareness, and just being able to have access to clean water, all of which are fairly simple to provide. I definitely agree that having sanitary water, proper hygiene, and the ability to administer antibiotics when needed are all crucial elements to preventing infection and ultimately death. I believe that this crisis would be relieved if other nations helped to donate funds and supplies to places such as Kiomboi, and if organizations such as WaterAid and Charity Water continue to supply clean water to these areas. Of course it will take time and effort for this to make the impact we desire, but by initiating the use and access of sanitary water and using proper hygiene, the need for antibiotics will be drastically decreased and the overall health of the nation will improve.

Often times in the United States we take water and proper sanitation for granted. This is a major issue in many countries where there isn't clean water because hand washing and proper sanitation act as a first line of defense against diseases. This post mentions that sepsis in newborns can be prevented if the hospitals have access to clean water and proper sanitation techniques. As a nursing student when I go into my clinical often times I notice that the nurses don't wash their hand and just use a hand sanitizer. It's not wrong but i still try to wash hands and many times the nurses also do it cause they see the students doing it. It's important to emphasize the importance of hand washing techniques and in countries where clean water isn't accessible see what can be done.

As an American Nurse, it's easy to forget the abundance of the most common and important natural resource on the planet. Water is essential on so many levels and the shortage of supply is indeed a serious health concern. The simple fact that infant mortality rate from sepsis alone is 18-20% speaks volumes. Clean water must be a priority for any healthcare facility regardless of it's location. Governments should place a priority in order to address this tantamount issue. Access to water and clean water technologies are now cost effective and simple to apply. Rain collection, condensation collection, and many other methods can provide plenty of water to facilities in need.
When substituting clean water with antibiotics, the risks far outweigh the rewards. Resistance to antibiotics increases and put another burden on top of a facility that doesn't even have clean water to begin with. This is a health crisis that leads to other health crisis worldwide. Considering the prevalence of antibiotic resistant bacteria, the problem will only get worse by over administration of antibiotics. I couldn't agree more that something needs to be done to gain access to clean water in order to combat infections and reduce antibiotic resistant bacteria.

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